Anticoagulant and antiplatelet therapy choices for patients with atrial fibrillation one year after coronary stenting or acute coronary syndrome

ABSTRACT

Introduction: Guidelines recommend a combined anticoagulant and antiplatelet approach for patients with atrial fibrillation (AF) after coronary stenting (CS) or acute coronary syndrome (ACS). Finding the optimal balance of reducing ischemic risk and minimizing bleeding risk is challenging. Recent trials have evaluated a variety of regimens for up to one year for AF patients after CS/ACS. Little empiric evidence exists about the best antithrombotic strategy beyond one year.

Areas covered: In this review two key areas are covered. First, a summary of the overall risk and benefits of anticoagulant and antiplatelet therapy in patients with AF and CS or ACS is provided. Second, despite limited empiric evidence to guide therapeutic decisions for combined anticoagulant and antiplatelet therapy in patients with AF one year after CS/ACS we provide guidance for shared patient-physician decision making.

Expert opinion: The evidence is limited. For all patients with AF and stable CAD (≥1 year after CS or ACS) the risk for thromboembolism, cardiovascular events and bleeding should be assessed individually. For patients with low bleeding risk and high risk for cardiovascular events, antiplatelet therapy might be added to anticoagulant therapy.

KEYWORDS:

• Atrial fibrillation
• coronary artery disease
• antiplatelet therapy
• oral anticoagulation
• coronary stenting
• percutaneous coronary intervention
• acute coronary syndrome
• myocardial infarction
• stable coronary artery disease

Article highlights

• Most patients with AF have an indication for OAC.

• NOAC offer additional benefits regarding CV outcomes compared with VKA.

• For AF patients with stable CAD (≥1 year after CS or ACS) the best anticoagulant and antiplatelet approach remains unknown as no data from RCT exist.

• Observational data suggest that APT in addition to OAC is associated with an increased bleeding risk without a lower risk of ischemic events.

• In patients with low bleeding risk and high risk for CV events however, additional platelet inhibition might be considered.

• Adequately powered trials are needed to identify the optimal anti-thrombotic strategy for those patients

This box summarizes key points contained in the article.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

Christoph B. Olivier was supported by a grant from the Deutsche Forschungsgemeinschaft OL371/2-1.